Healthcare Provider Details

I. General information

NPI: 1356337646
Provider Name (Legal Business Name): EMMETT FULCHER MONTGOMERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 KNOX CT STE 100
DAVIDSON NC
28036-0590
US

IV. Provider business mailing address

PO BOX 4329
DAVIDSON NC
28036-4329
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-5454
  • Fax: 704-892-5858
Mailing address:
  • Phone: 704-892-5454
  • Fax: 704-892-5858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35242
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: